Who We Are: UChicago Medicine

Collaborative Care is an evidence-based model of care that increases the capacity for mental health care in non-psychiatry settings. 

Patients with depression and/or anxiety or with cognitive impairment with mental health and/or neuropsychiatric problems.

A social worker will talk with your patient by phone, video, or in-person at least every 2 weeks and consult with a psychiatrist every week.

• Care Management: Coordinate between PCP and consultative psychiatry, assess medication adherence, and provide other mental health services such as connection to long-term therapy.
• Psychiatric consultation: Assisting with diagnoses and medication adjustments.
• Brief therapy: Biweekly psychoeducation, brief CBT, motivational interviewing, supportive counseling

Outreach & Engagement: Understands our vulnerable populations and builds trust to engage patients in health activities, including home visits.

Care Coordination: Helps patients navigate the healthcare system to schedule appointments, work through insurance issues, etc.

Health Education: Provides culturally competent health education and resources.

Advocacy & Support: Advocates for the needs of the patients in the community and connects to community-based resources.

Care Coordination

• Facilitates communication among various healthcare providers and settings
• Develops comprehensive patient centered education

Patient Education

• Educates about conditions treatment options medication management and self-care techniques

Resource Management

• Assists in accessing necessary resources and support services

Patient Advocacy

• Advocates for patients to ensure needs and preferences are prioritized in treatment and care decisions

Post Acute

• Follows patients during post acute stays to eliminate barriers and ensure timely discharges

Patient Access Specialists: Outreach patients to schedule them for Annual Wellness Visits and educate on the importance of preventative health measures.

Coding Documentation Specialists: Review charts and make recommendations for accurate HCC coding.

Population Health Coaches: Outreach patients to pull in for needed services (colonoscopy, mammogram, etc.) and help close quality gaps. Submit all necessary documentation to payers in order to achieve optimal quality performance scores.